Tachycardia, tremor and hypertension during extraction in a patient with stable angina on a beta-blocker
Mr T, 67, needs extraction of 26, 27 and 36 because of unrestorable caries and recurrent periapical infection. He has hypertension and stable angina, with his last anginal episode 2 years ago, and takes atenolol 50 mg, ramipril 5 mg, atorvastatin 20 mg and aspirin 100 mg daily. He reports no allergies. Baseline blood pressure is 148/88 mmHg and his pulse is 72 beats/min and regular. After two cartridges of 4% articaine with 1:100,000 adrenaline (3.4 mL) for the maxillary extractions, he becomes tremulous and sweaty, reports a pounding heart and feels panicky. His pulse is 112 beats/min and blood pressure 178/96 mmHg. He has no chest pain and no breathlessness, and his skin is warm and dry. Tooth 26 has already been extracted; 27 and 36 remain. He asks whether he is having a heart attack.
1. Set out your immediate management, and explain how you distinguish an adrenaline reaction, anxiety and angina in this situation.
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Stop and stabilise. Stop the procedure, remove instruments and debris from the mouth, sit him semi-reclined (he is hypertensive, not syncopal), give oxygen by nasal cannula, and reassure him in a calm, confident voice. Take blood pressure, pulse and oxygen saturation immediately and repeat every 5 minutes. Have him describe the sensation: is it a pounding in the chest or a pressure? Does it radiate to the jaw, neck or arm? Any breathlessness, nausea or cold sweat?
Discriminate using the pattern.
- Adrenaline reaction: palpitations, fine tremor, anxiety, pallor, rise in both heart rate and blood pressure, warm dry skin, settling over 5-10 minutes as the catecholamine effect fades. Typically follows inadvertent intravascular injection or a dose near the cardiac limit.
- Vasovagal syncope or anxiety: bradycardia with falling blood pressure, cold clammy skin, pallor, nausea, light-headedness.
- Angina: retrosternal pressure or tightness, often radiating, provoked by stress, with dyspnoea or diaphoresis; relieved by sublingual GTN; may be accompanied by ischaemic ECG change.
Apply this to Mr T. Tremor, a warm dry skin, no chest pain, and tachycardia with hypertension after a catecholamine-containing local anaesthetic fit an adrenaline reaction with anxiety. Note that his atenolol has not prevented a pulse of 112 - the sympathetic drive is substantial.
Then what. Reassure him that this is not a heart attack but a reaction to the anaesthetic, monitor until pulse and pressure return towards baseline, and defer 36 to another visit even if he settles. If chest pain, dyspnoea or persistent symptoms appear, call emergency services, give sublingual GTN, oxygen, and have him chew 300 mg aspirin.
2. Calculate the doses he received and the relevant maximums, and state what you would do differently at the next appointment.
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What he received.
- Articaine 4% = 40 mg/mL. 3.4 mL = 136 mg.
- Adrenaline 1:100,000 = 10 micrograms/mL. 3.4 mL = 34 micrograms (0.034 mg).
Maximums. Articaine is usually quoted at 7 mg/kg, capped around 500 mg; for an 80 kg adult that is roughly 500-560 mg, so the articaine dose was modest. For adrenaline, healthy adults tolerate up to about 0.2 mg, but in patients with cardiac disease the accepted ceiling is around 0.04 mg (40 micrograms), i.e. about two cartridges of 1:100,000. He was therefore close to the cardiac limit, and a single intravascular injection of even part of that bolus would explain his symptoms.
Next appointment - change the technique, not just the drug.
- Limit total adrenaline to 40 micrograms; treat one or two teeth per visit rather than three.
- Aspirate in two planes before every injection and inject slowly - roughly 1 mL per minute - because the reaction is about intravascular delivery, not just total dose.
- Use the smallest effective volume; consider infiltration rather than a block where the tooth allows.
- Short morning appointment, with him having taken his medication as usual, having eaten, and having his GTN inhaler with him.
- Monitor blood pressure before and during; have oxygen and GTN to hand.
- Do not stop his aspirin; local measures control post-extraction bleeding.
- If several extractions are unavoidable and he is highly anxious, consider anxiolytic premedication with caution (additive sedation with his beta-blocker) or referral for treatment under sedation or general anaesthesia.
3. State your discharge criteria and what you would tell him about his aspirin and his angina before he leaves.
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Discharge criteria. All symptoms resolved; pulse and blood pressure back within roughly 20% of his baseline and stable over at least 15-30 minutes of observation; no chest pain, dyspnoea or dizziness; haemostasis secured at the extraction site; able to stand and walk without light-headedness; accompanied home; written post-operative instructions, an emergency contact number, and a clear instruction to call emergency services if chest pain occurs at home.
Aspirin. Continue it. Do not stop antiplatelet therapy for a dental extraction without consulting his cardiologist - the thrombotic risk outweighs a bleeding risk that is almost always manageable with local measures (pressure pack, sutures, haemostatic agent, tranexamic mouthwash if needed). If bleeding occurs at home, he should apply firm pressure with a rolled gauze for 20 minutes and call the practice rather than skip a dose.
Angina. Stable angina is not a contraindication to dental treatment. Tell him to bring his GTN to every appointment, to use it prophylactically if he expects a stressful visit, and to tell you immediately if he feels chest tightness so that treatment stops. Explain the difference between his usual stable pattern and a crescendo or rest pattern, and instruct him to report any change - if his angina becomes unpredictable, elective treatment is deferred and he is referred back to cardiology.
Document the event, the readings, the doses given, the discussion and the plan for the next visit.